Gastrointestinal Bleeding from Metastatic Melanoma
An 85-year-old man presented to the emergency department after losing consciousness and collapsing. He had regained consciousness by the time of presentation and reported a 2-week history of passing dark stools. He had a history of two cancers: breast cancer, for which he was receiving treatment with goserelin and letrozole, and nodular melanoma, for which he had undergone a wide local excision on the right arm and dissection of the axillary lymph nodes 5 months earlier. The heart rate was 110 beats per minute, and the blood pressure was 115/70. He was pale, and there was evidence of ongoing melena with no abdominal tenderness. Laboratory studies showed a hemoglobin level of 7.6 g per deciliter (normal range, 11.5 to 15.5), and he received 1 unit of red cells. Endoscopy revealed multiple polypoid nodules with a central depression and evidence of recent, but not active, bleeding in the stomach. The results of histologic analysis of biopsy samples were consistent with metastatic melanoma. Computed tomography showed thickening of the stomach wall and lining, along with metastases in the brain, lung, and liver. Despite treatment with palliative radiation and pembrolizumab, he presented 3 months later with further episodes of melena as well as multiple other complications. He was transitioned to hospice care and died shortly thereafter.
